Inspection on 07/08/06 for Burntwood Lodge

This inspection was carried out on 7th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burntwood Lodge 08/07/08

Burntwood Lodge 09/07/07

Burntwood Lodge 19/01/06

Burntwood Lodge 21/04/05

Burntwood Lodge 16/11/04

Burntwood Lodge 26/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Sutton Lodge Nursing Home

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Burntwood Lodge Burntwood Lodge 84 Burntwood Lane Caterham-on-the-hill Surrey CR3 6TA Lead Inspector Joseph Croft Unannounced Inspection 7th August 2006 09:30 Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burntwood Lodge Address Burntwood Lodge 84 Burntwood Lane Caterham-on-the-hill Surrey CR3 6TA 01883 330525 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Abdulha Aziz Coowar Sally Margaret Skinner Care Home 6 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1), Mental disorder, excluding of places learning disability or dementia (1), Physical disability over 65 years of age (2), Sensory impairment (2) Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age range of those accommodated shall be 43 - 65 years of age and 2 residents over 65 years of age 19th January 2006 Date of last inspection Brief Description of the Service: Burntwood Lodge is a registered care home, providing care and accommodation for up to six adults with learning difficulties. The home is set in a quiet residential area, with shops and other amenities a short drive away. All six rooms were occupied, one single room with ensuite facilities, one double shared room, and four single rooms. Communal rooms comprise a spacious lounge, dining room, kitchen and bath/shower room. The area to the rear of the main house has a patio area and a large garden. The fees are £800 to £1000 per week. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Key Inspection using the Inspection for Better Lives process for the year 2006/2007. This key inspection ensured that all the core standards of the National Minimum Standards for Younger Adults were considered. This inspection was unannounced therefore staff and residents were not informed in advance of the inspection being carried out. The inspection process included a tour of the premises, sampling of residents’ care plans, risk assessments, staff training records and staff recruitment files; other documents sampled included policies and procedures, staff duty rota, menu, medication and records of medicines. Discussions took place with the manager, staff, and residents who were at the home at the time of the inspection. There are currently six residents living at the home. Due to their low levels of understanding, discussions with residents were limited. During discussions residents stated they were happy living in the home, that the food was good and they liked the activities offered. Residents’ bedrooms had their personal belongings such as televisions, pictures, and family photographs. Residents stated that they like the staff, and they help them to make choices regarding their daily lives. Discussions took place with staff on duty at the time of the inspection. Staff were knowledgeable about residents’ care plans, their likes and dislikes, and how to support residents. Feedback was provided at the end of the inspection to the manager and the registered provider. The inspector would like to thank the staff and residents for their cooperation during the inspection. What the service does well: Prospective residents are provided with appropriate information about the home. Staff in the home encourage and enable residents to participate in a range of activities both within the home and the local community. The home offers a healthy balanced diet. Physical and emotional health care is offered in such a way as to promote residents independence. The residents are protected by the home’s storage, administering and recording medication policies and procedures. Residents are supported and protected by the home’s recruitment procedure. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with appropriate information about the home and have their needs assessed to ensure they can make an informed choice about where to live. EVIDENCE: The home has a sister home within the organisation, and the two managers and the registered person have worked together to produce a comprehensive Statement of Purpose and Service Users Guide. This provides clear information of what the home offers, the care philosophy, aims and objectives, statement of rights, services offered, how to make a complaint, daily routines and organised activities. The manager stated the home is to invest in computer software that will enable the Service Users Guide to be written using symbols and pictures to ensure all current and prospective residents can easily understand the contents. The manager and staff stated residents had been provided with a copy of the Service Users Guide, but they kept returning their copies to the office. The home has an admissions policy and procedure that is followed when referrals to the home are made. This provides clear step-by-step guidelines on the process for admitting new residents to the home, clearly stating the criteria and process for admission. The manager stated the home has not had a new Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 9 admission recently, but the admissions procedure would be followed when new referrals are made to the home. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has care plans in place that ensure the needs of the residents are met, however, two identified areas did not have risk assessments in place. EVIDENCE: Three care plans were sampled during this inspection. Care plans included information in regard to the resident’s GP, medication, allergies, communication, personal awareness, showering, washing and manicure/pedicure. Evidence was viewed that care plans are reviewed every six months. It was noted that residents’ had not signed their care plans. The manager stated that a full review of all care plans is to be undertaken with residents and their families, and this will include care plans being signed by residents and/or their representatives. A requirement has been made in regard to this. During discussion the manager stated that Person Centred Plans (PCP) is to be introduced for all residents living at the home, and that training in regard to PCPs is to be provided to all staff. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 11 Residents have a low level of understanding, and did not fully understand the concept of ‘care plans’. One resident spoken to was able to bring her care file to the inspector, and show the photograph of herself on the inside cover. Residents were aware they could talk to all care staff, and that they support and help them when required. Residents were able to state the activities they like to attend, which reflected the recordings in their care plans. Records of decisions made by residents are maintained in the daily records kept by the home. It was observed in two care plans that staff had written a small book with the resident entitled ‘My Choices’, which details the residents’ likes and dislikes. It gave information in regard to weekly activities and hobbies and interests. The manager stated these are to be produced for all residents. During discussions, staff were able to give an account of the content of care plans for the residents with whom they key work, were aware of the need to review care plans every six months, and when required. Evidence of statutory annual reviews was observed in the care plans sampled. Evidence was viewed of individual risk assessments in the care plans, and included risks on falls, accessing the home’s transport, fire alarms, walking and using the kitchen. All risk assessments were last reviewed on the 12th January 2006. It was noted that there was not a risk assessment in regard one identified resident who has epilepsy, nor was there a risk assessment in regard to the use of the bedside rails. A requirement has been made in regard to these. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given opportunities to improve their lifestyle and are offered a healthy balanced diet. EVIDENCE: The manager stated that no resident is in any form of employment. During discussions residents stated that they choose the activities they like to take part in, which include art, craft, cooking, puzzles, shopping and trips into the local community. Care plans sampled provided evidence that residents had attended day centres, but through their choice they no longer go. Only one resident living at the home regularly attends a day centre. Each resident has their own weekly activity programme, which provided evidence that residents attend gentle exercise, music, art, hydrotherapy, a sensory room and a local museum. In house activities included, art and craft, music and puzzles. During the inspection residents were observed going out of Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 13 the home for activities. The manager stated the individual activity programme is to be updated to include all internal and external activities for individuals. During discussions, staff and residents stated they go to restaurants, a local football club, shopping trips, seaside and go to different pubs for lunch. Staff stated residents are able to go to Church if they ask, with staff support. The manager stated all residents living at the home are white British, and do not have an understanding of racial and cultural issues. During discussions staff and the manager stated families are encouraged to visit on a regular basis, however, due to the aging group of relatives, this is somewhat limited. Residents stated their family visit them. One resident stated she regularly goes home at weekends to stay with her Mum. The manager stated the two homes in the organisation hold an annual BBQ for family and friends to attend. Residents are able to choose whom they would like to see. Evidence of family visits were observed recorded in the daily records. The manager stated all staff knock and wait to be invited into bedrooms; this was confirmed during discussions with staff and observations during the inspection. Residents are able to make and receive telephone calls from the privacy of their bedrooms through the use of the home’s cordless telephone. Staff stated they assist residents as and when required. Residents receive their own letters, and again staff offer assistance. At the time of the inspection, residents were dressed in their own clothes. During discussions residents stated the staff were nice to them and helped them when they needed it. The manager stated a hairdresser used to visit the home every six weeks, but now residents go to the hairdresser in the local community. Residents were observed to have unrestricted access to all communal parts of the home. The home uses a four-week rolling menu that was viewed during the inspection, and offers balanced and appetising meals with fresh vegetables and fruit. Evidence of fridge/freezer temperature records were observed, and records of variations from menu were recorded in daily notes. During discussions, residents stated they could choose the meals they like and they help with the shopping. Evidence that residents are consulted about the menus was viewed in residents meeting notes and resident surveys. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Physical and emotional health care is offered in such a way as to promote residents’ independence. The residents are protected by the home’s storage, administering and recording medication policies and procedures. EVIDENCE: During discussions, staff stated that personal support is offered to residents who request it, and by staff of the same sex. Staff stated this is undertaken in a private and sensitive way to protect the dignity of the resident. Arrangements regarding areas of health care are detailed in residents care plans. Records of visits by the GP, and attendance to the Dentist, Opticians, Chiropodist, and other health care professionals are also maintained. However, these records must be further developed to record details of medical treatment received, and any known side effects of medication prescribed to the resident. A requirement in regard to this has been made. Residents have access to all NHS healthcare facilities as required. Incidents of illness are recorded in daily records and healthcare plans. All residents have an annual health care review on their Birthday. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 15 The home has produced a comprehensive Medication Policy dated May 2005, which details clear guidance to all staff who administers medication. Medical records sampled provided evidence that accurate records of medicines dispensed are clearly maintained. The home maintains records of medicines received and returned to the Pharmacist. Medication is appropriately stored in a locked metal medical cabinet. The manager stated no resident is currently taking a prescribed controlled drug, and no resident is self-medicating. Training records in the Safe Administration of Medication for staff who dispense medication were viewed. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system to enable residents and their families to raise concerns. Residents are protected by staff having knowledge and understanding of adult protection issues, but policies and procedures must be reviewed. EVIDENCE: The home has a clear Complaints Policy and Procedure dated May 2005. This gives clear procedures and guidance of how to make a complaint, who to complain to, timescale for responding and investigating complaints, and includes the Commission For Social Care Inspection Surrey Local Office contact details. During discussions, residents stated they would talk to staff if they were unhappy or wanted to make a complaint. Staff spoken to stated that they had read and understood the Complaints Policy and Procedure, and gave an accurate account of whom they would report complaints to. Staff stated they would not hesitate in reporting concerns to the Commission For Social Care Inspection Surrey Local Office. The complaints book was viewed and evidenced there had been no complaints made since last inspection. The complaints book details the date, name of the person complaining, nature of complaint, action taken, and the date feedback was provided to the complainant. The home has a Protection of Vulnerable Adults Policy, which is dated May 2005, however, this must be reviewed and updated in line with the Surrey Multi-Agency guidelines on the Protection of Vulnerable Adults. During Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 17 discussions staff gave an accurate account of what to do if they witnessed or suspected that a resident is being, or had been abused. Staff stated they would have no hesitation in reporting bad practice, and if necessary, they would report their concerns to the Commission For Social Care Inspection Surrey Local Office. Evidence of staff training in the Protection of Vulnerable Adults was observed. The manager had attended the Surrey Multi-Agency training in the Protection of Vulnerable Adults on the 29th June 2006. The home has a ‘Whistle Blowing Policy’. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The general standard of the environment requires attention to ensure residents are provided with a safe, secure and homely place to live. EVIDENCE: A tour of the premises was undertaken. The home has recently had the lounge, entrance hall and a shower room redecorated. The kitchen facilities were noted to be old and in need of attention to the décor and cupboard doors. During discussions, the registered person stated the whole of the kitchen is to be refurbished in the New Year. It was noted the laundry facilities remain accessible by walking through the dining room and part of the kitchen. A requirement has been made that the registered person must submit to the Commission For Social Care Inspection Surrey Local Office an action plan with dates in regard to the refurbishment of the kitchen and the moving of the laundry facilities. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 19 The home has a garden to the rear of the premises, which requires attention. It was observed that the garden fence is in need of repair, and a missing fence panel must be replaced. A requirement in regard to this has been made. The manager must write a risk assessment in regard to the use of the garden whilst awaiting the repair of the fences. Bedrooms were appropriately furnished with resident’s personal belongings such as televisions and family photographs. During discussions residents stated they liked their bedrooms. It was noted that some residents have specialist beds, however, these had not been regularly serviced. A requirement in regard to this has been made under Standard 42. Residents have unrestricted access to the lounges, dining room and garden. Residents were observed using the communal areas during the inspection. The home has an Infection Control Policy which provides guidance on the legal responsibilities, including the handling and disposal of soiled waste, protective clothing, cleaning of spillage, storage, preparation and serving of food and the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations. During discussions, staff stated they had read all Policies and Procedures written for the home. On the day of the inspection the home was found to be clean, tidy and free from offensive odours. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported and protected by the home’s recruitment procedure. EVIDENCE: On the day of the inspection the home employed twelve members of care staff plus the manager, three of whom worked part time hours, and another three are students who work no more than twenty hours per week. The duty rota for the week of the inspection was viewed, and evidenced that there are three members of staff on duty each shift. On some days the manager is supernumerary to staff. There is one waking night staff and one sleep-in person each night. During discussions, residents stated they could always get help during the night if they required. The manager stated that she and the deputy manager take turns to do on call duties at the weekends. Evidence was viewed that one member of staff holds the NVQ level 3. The manager stated three members of staff are currently studying NVQ level 2, and one member of staff is studying NVQ 3. The home has a satisfactory Recruitment Policy and Procedure that is followed when recruiting new staff. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 21 Recruitment files sampled on the day of the inspection contained all the necessary documentation as required, including proof of identity. The training and development of staff continues to progress. During discussions staff stated they had received all mandatory training during the last twelve months. Although evidence of training was viewed in staff files, it was noted that staff do not have individual training and development assessment profiles. A requirement has been made in regard to this. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for management and administration ensure the home is run in the best interests of residents, however, the safety of residents must be promoted at all times. EVIDENCE: The home has a new manager who was successfully registered with the Commission For Social Care Inspection Surrey Local Office in June 2006. The manager has six years experience in working with adults, two of which have been at a senior level. The manager has successfully completed the Registered Managers’ Award (RMA), is currently undertaking the NVQ level 4, and attended the Surrey Multi-Agency training in the Protection of Vulnerable Adults on the 29th June 2006. The manager attends all the mandatory training provided for staff. Certificated evidenced of the training undertaken by the manager was viewed. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 23 Quality assurance surveys were viewed, these evidenced that the home’s management seeks the views of residents and staff in regard to the care provided by the home, and future developments within the home. However, it was noted that this has not been extended to residents’ families and/or representatives. A requirement in regard to this has been made. The home’s owner continues to visit the home on a daily basis, and conducts Regulation 26 reports, which were evidenced during this inspection. Training files sampled evidenced the following mandatory training had been undertaken: food hygiene and handling, first aid, 4/11/05, Protection of Vulnerable Adults, 9/12/05, health and safety and manual handling, 25/11/05, medication, 2/12/05, and fire safety, 23/5/06. The following health and safety checks of the home were evidenced during this inspection; fire drills, testing and maintenance of fire detection and prevention equipment, fire risk assessments, legionella, gas boiler, electrical certificate, portable electrical appliance testing, COSHH register, fridge/freezer and cooking temperatures, weekly monitoring of the hot water outlets. It was noted that the specialist beds used in the home had not been subject to annual servicing. The registered person must ensure an appropriately qualified person, approved by the bed manufacturers, service the specialist beds used in the home on an annual basis. Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 2 X Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (1) Requirement The manager must ensure residents and/or their representatives sign the care plans. The manager must write a risk assessment in regard to epilepsy for one identified resident. Risk assessments on the use of the bed rails must be written. Health care plans must include details of medical treatment received, and any known side effects of medication prescribed to the resident. The manager must review and update the Protection of Vulnerable Adults Policy and Procedure to ensure it is written in line with the Surrey MultiAgency guidelines on the Protection of Vulnerable Adults. The manager must write a risk assessment in regard to the use of the garden whilst awaiting the repair of the fences. The registered person must submit an action plan with dates in regard to the repair of the garden fence. The registered person must DS0000013582.V306087.R01.S.doc Timescale for action 07/09/06 2. 3. 4. YA9 13 (4) (c) 13 (4) (c) 13 (3) Sch 3 14/08/06 14/08/06 14/08/06 YA9 YA19 5. YA23 13 (6) 21/08/06 6. YA28 13 4 (a) 14/08/06 7. YA28 23 (2) (a) (b) (c) 23 (2) (a) 21/08/06 8. YA28 21/08/06 Page 26 Burntwood Lodge Version 5.2 (b) (c) submit to the Commission For Social Care Inspection Surrey Local Office an action plan with dates in regard to the refurbishment of the kitchen and the reciting of the laundry facilities. The registered person must ensure that all staff have individual training and development assessment profile. The registered person must develop a system to ascertain the views of residents’ representatives in regard to the quality of care they receive The registered person must ensure an appropriate qualified person approved by the bed manufacturers service specialist beds used in the home on an annual basis. 01/09/06 9. YA35 18 10. YA39 24 (3) 01/09/06 11. YA42 23 (2) (c) 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Burntwood Lodge DS0000013582.V306087.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!